The WHO in Belgium: cross-level networking

Since the eighties, the Belgian mental health sector has faced several reforms. Still dominated by the hospital facilities, as the principal device for the treatment of mental diseases, this sector has initiated a long process of reform towards the development of a system of collaborative interprofessional networks aimed at the resocialization of the chronic patients. Since the beginning of the century, the World Health Organization (WHO) has become more and more active on the issue of mental illness. This work culminated in 2005, with the Declaration of Helsinki which emphasized the necessity of a paradigm shift: from psychiatry towards mental health; from the hospital towards the community cares. The reappropriation of this work in the direct aftermath of Helsinki by the European Union contributed to increase the pressure on Belgium for change. This report propose to analyze the role of the WHO’s declaration of Helsinki in the process of reform of the Belgian mental health sector.

WHO and Belgium: a network of experts in a segmented context

Deprived of legal constraints, the WHO seems to exist in Belgium through a network of actors that relay information among the various actors in the sector. This small interknowledge community manages to collaborate at various levels according to the current climate and moments which open up – or not – the doors of the ministerial cabinets. Dependent on relations with the competent ministers, this network is also led by heterogeneous dynamics according to which community they belong. Founded by uniting members of philosophical and different linguistic communities, they nevertheless manage to affect actors at numerous levels. Since they hold a variety of positions at a national and international level but also in local projects, they can also be the relays of knowledge produced and distributed by the WHO. If these actors try to keep the reforms on the political agenda, they just can do so by informing the sector and without being too prescriptive or constraining. Presenting themselves as facilitators and providing expertise when asked for, their strategy is the one of interessement.

Indeed, Belgium is structured into different philosophical and linguistic communities. The distribution of competences is relatively complex and can have consequences in terms of acceptance and implementation of international knowledge. In facts, these particularities participate in the act of functioning through compromise – the “Belgian compromise” – which is related to the consociative model of democracy. Indeed, decision-making in Belgium in terms of health as in other sectors, is never or rarely unilateral but the result of negotiations with many stakeholders and the theme of deinstitutionalization is very sensitive.

WHO performing in Belgium

At first view, the Helsinki process may seem to have had a considerable effect on the Belgian policy considering the number of references to the action plan among the official documents defining the major policy orientations in the sector. More troubling was the decision to create a pilot project putting into operation a care network – a recommendation that was part of the Helsinki action plan – taken in 2005, a few weeks after the WHO conference. The general policy note of the minister presenting the project refers to the WHO and its 2001 report in the introduction. Reference is also made to numerous others. However, an attaché to the minister’s cabinet points out: “But the Belgian reports are not a reaction to European reports…”; and when asking if a specific policy was elaborated in response to the Helsinki’s Declaration, the answer is unanimous: “As far as I know, nothing!”.

Following Helsinki, the Minister of Health, ordered the WHO Collaborating Centre, via his public administration, FPS Health, to carry out a feasibility study of the implementation of the plan in Belgium. The work was conducted by a multidisciplinary team including psychiatrists, psychologists and sociologists, and organized into two major parts. The first one consisted of an inventory of all the actions carried out in Belgium by all levels of power in the field of mental health. The second part consisted of a series of “validation seminars” whose confirmed objective was to reach a consensus, on the basis of the results of the first part, among a panel of experts, practitioners, and heads from various regions and structures, on the strengths and weaknesses of mental health policies in Belgium.

This activity of discussion and the cycle of validation, as other examples, shed lights upon another phenomenon. The Declaration of Helsinki does not constitute a clear guide for action. While it creates the adherence of the majority of actors, they nevertheless do not grasp the direct usefulness or exact reach of it. These norms have to be discussed, negotiated, tested, and related to the local context. In one word, they have to be appropriated and translated by the actors. Appraised from a situated rationality, the WHO recommendations do not seem to provide univocal action guidelines but rather a form of support, a resource for the search for “possible worlds” or for legitimization.

Conclusion: WHO performing through loops of translation

If Helsinki has not led to a specific policy in Belgium, this does not mean that these standards have not been effective. Indeed, the analysis of the relations between Belgium and the WHO suggest that we should move away from a hierarchical political model with a “top-down” influence. Providing resources for the definition of new policies and a certain legitimacy to maintain these issues on the agenda, the resulting influence seems to occur through far more sinuous and slow routes, requiring an intense activity of translation into local contexts. The WHO’s various recommendations only seem to exist as being retranslated into the present stakes On the other hand, the European Union seems to provide less cognitive resources than pressures for change.

We must therefore take an interest in these local projects, which reappropriate these recommendations through associations or external actors. Whether they are therapeutic projects, users’ associations or pressure groups, the analysis of this reappropriation and the dynamics which convey the information to more global positions through advisory organs or assessment mechanisms, is likely to enrich our understanding of the role of knowledge in the reconfigurations of public action. The study of these “strange loops” will thus fall under the scope of a perspective that takes into account the role played by all the “stakeholders” without, however, focusing on the political elites alone and the highest spheres of the State in accordance with the approach in terms of public action.